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THE JOURNAL OF FEMALE
URINARY INCONTINENCE

Commented Abstracts

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Pubovaginal Slings using Fascia Lata for the treatment of intrinsic sphincter deficiency.
Govier, F.E. ; Gibbons, R.P. ; Correia, R.J. ; Weissman. ; Pritchet, T.R. and Hefty, J.R.
From the section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, Washington. J. Urol., v.157, p.117-21,1997.

ABSTRACT

Purpose: Various material and techniques have been used to construct a pubovaginal sling. We believe that fascia lata has several advantages and report our experience.
Materials and Methods: A total of 32 female patients with urodynamically proved intrinsic sphincter deficiency underwent a pubovaginal sling procedure using fascia lata. An unscarred fascial strip 24 to 28 X 2 cm. Was attached to itself over a 3 a 4 cm. bridge of abdominal wall fascia (Figure 1, 2, 3, 4) . Results were tabulated by chart review and na independent patient survey.
Results: Chart review revealed that 28 of 32 patients (87%) required no pads, and 3 improved and 1 did not. An independent patient survey revealed that 70% of patients (21 of 30) required no pads, 20% required 1 to 3 small pads and 10% required more than 3 small pads per day. Of the patients 80% would undergo the procedure again.
Conclusions: Excellent results can be obtained with fascia lata for the treatment of intrinsic sphincter deficiency. A long , wide strip of fascia attached to itself allows for precise tensioning and good urethral closure, and minimizes the risk of obstruction.

 

EDITORIAL COMMENT

Urinary incontinence in women caused by intrinsic sphicterian deficiency (ISD) is traditionaly treated with a pulbovaginal sling. Since the beginning of the century many surgical materials and techniques have been proposed, the most used being the aponevrotic strip from the abdomen anterior rectum, using double surgical route approach, this means, abdominal and vaginal way.
These techniques were mostly forgotten for a certain period of time, but recently have been rescued and made popular, mainly after the work of McGuirre & Lytton, 1978 1.
In the discussed article the authors present the results of the 32 patients underwent a pubovaginal sling procedure using fascia lata with ISD. The majority had been submited to previous surgeries.
The results of the surgical evaluation are:

  • Excellent (patients that are completely continent);

  • Good (slight leak without need of pads);

  • Improved (needs a change of 2 or 3 pads a day) ;

  • Failure (needs more than 3 pads changes a day).

The authors present the surgical results with 2 methods of evaluation. The first method consists of written answers given by the patients to a questionary that was handed to them. The second method of the evaluation resulted in a telephone interview by a clinical nurse.
It calls to our attention the great disparaty of the answers obtained by both methods. The differences of the evaluation between the 1st. and 2nd. method were the following, respectively: Excellent - 78 and 33%; Good - 9 and37 %; Fair - 9 and 20%; Failure - 4 and 10%.
The follow up of continuation was relatively short, varying from 3 to 33 months, with an average of 14 months.
The authors consider themselves satisfied with the results they obtained and they emphasized the following advantages with the use of the fascia lata :

  • The fascia lata supplies a long aponevrotic strip (18 to 22 cm.) with a good thickness, an absence of scars, permitting good technical conditions for the carrying out of the "sling"getting an excellent urethral closing with a low risk of obstruction;

  • Because there is no removal of abdominal fascia, hospitalization is short, there is no risk of formation of abdominal hernia and returning to activities is sooner (4 weeks).

One important technical aspect discussed in this article refers to the degree of tension that is given to the aponevrotic strip and the possibility of this tension to be raised gradually at the cost of suture stitches, till you reach a desired tension.
However what must be evident is that the authors do not present an objective parameter to establish the adequate degree of tension to each case. That is the critical point of all "sling" techniques and the tension given to the aponevrotic strip or any other material, always have an extremely subjective component.
The lack of tension, or the contrary, excessive tension, are factors that cause the persistency of urinary incontinence leading to the failure of those techniques, or then, the occurrence of urinary obstruction in the post-operatory of these surgeries, that need an indication of intermitent catheterism for long periods of time.
The non adequate solution of the critical point of this surgical technique certainly is responsible for the elevated number of non satisfactory results, because, 67% of these patients (if we compute the 2nd method of the authors evaluation) will continue to present urinary leak of a lesser or higher magnitude.

Josť Carlos Souza Trindade


1. MC GUIRE, E.J.; LYTTON,B. Pubovaginal sling procedures for stress incontinence. J. Urol., v.119, p.82, 1978.

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